Chronic Heart Failure
Summary
Chronic heart failure (CHF) is a clinical syndrome with symptoms and signs of fluid retention and/or reduced cardiac output. HFrEF (LVEF 40% or less) has the strongest treatment evidence. Guideline-directed medical therapy (GDMT) includes four pillars: ACEi/ARB/ARNI, beta-blocker, MRA, and SGLT2 inhibitor. All four reduce mortality and hospitalisation. Device therapy (ICD, CRT) is indicated in selected patients.
Key Facts
- Definition: Syndrome of impaired cardiac function with symptoms
- Incidence: 1-2% prevalence; increases with age
- Pathognomonic: Symptoms + elevated BNP + structural/functional abnormality
- Gold Standard Investigation: Echocardiography
- First-line Treatment: Four pillars: ACEi/ARNI + BB + MRA + SGLT2i
- Prognosis: Variable; GDMT significantly improves outcomes
Clinical Pearls
Four Pillars Pearl: All HFrEF patients should be on all four classes if tolerated.
ARNI Pearl: Sacubitril-valsartan superior to ACEi for HFrEF (PARADIGM-HF).
SGLT2 Pearl: SGLT2i beneficial regardless of diabetes status (DAPA-HF, EMPEROR).
| Type | LVEF |
|---|---|
| HFrEF | 40% or less |
| HFmrEF | 41-49% |
| HFpEF | 50%+ |
Algorithm
Four Pillars (HFrEF)
| Drug Class | Example |
|---|---|
| ACEi/ARB/ARNI | Sacubitril-valsartan, ramipril |
| Beta-blocker | Bisoprolol, carvedilol |
| MRA | Spironolactone, eplerenone |
| SGLT2 inhibitor | Dapagliflozin, empagliflozin |
Device Therapy
| Device | Indication |
|---|---|
| ICD | Primary prevention LVEF 35% or less + symptoms |
| CRT | LBBB QRS 150+ ms + LVEF 35% or less |
-
McDonagh TA et al. 2021 ESC Guidelines for heart failure. Eur Heart J. 2021;42(36):3599-3726. PMID: 34447992
-
NICE guideline NG106. Chronic heart failure. 2018.
Viva Points
"Chronic HF: four pillars - ACEi/ARNI, beta-blocker, MRA, SGLT2i. All reduce mortality. Device: ICD prevention, CRT if LBBB."
Last Reviewed: 2026-01-01 | MedVellum Editorial Team